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  5. FP839 : Superior Rectus Transposition vs Medial Rectus Recession for Treatment of Esotropic Duane Syndrome

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Dr. Kuldeep Kumar Srivastava, S06431

Authors

Affliations 

Purpose: To compare the results of medial rectus recession (MRc) combined with Superior rectus transposition (SRT) with MRc alone for treatment of esotropic Duane syndrome.

Method: The medical records of patients who underwent surgery for esotropic Duane syndrome between January 2011 and December 2016 were reviewed retrospectively.

Results: There were 6 patients in the SRT group and 12 in the MRc group. In the SRT group, the mean preoperative and postoperative deviation was 24PD and 4PD esotropia respectively. The preoperative and postoperative deviation in MRc group was 22 PD and 6 PD respectively.  The success rate (alignment within 10PD of orthotropia) was 80% in the SRT group; 70%, in MRc group. Mean abduction limitation improved from -3.5 to -2.4 units in the SRT group and from -3.6 to -3.0 units in the MRc group.

Conclusion: Although both the procedures successfully correct esotropia in Duane syndrome, MRc combined with SRT has the additional advantage of improving abduction.

Introduction

Patients with Duane Retraction syndrome usually have moderate to severe limitation of abduction, esotropia in primary position, associated compensatory head posture and diplopia on attempted abduction. Various surgical approaches including medial rectus recession, vertical rectus muscle transposition with or without medial rectus muscle recession have been proposed for improving eye position and head posture. Medial rectus muscle recessions improve esotropia and face turn but has little effect on abduction. Full vertical rectus transposition (VRT) procedures are the most effective procedure for treatment of the abduction deficit in esotropic DRS; however this procedure have been reported to produce vertical deviations in 8 to 40 % of patients 1–2. There is also a risk of anterior segment ischemia with this procedure, especially if combined with medial rectus muscle recession.3 Johnston and Crouch introduced a modification of the VRT in which only the superior rectus muscle is transposed.4 Since then several authors have adopted this superior rectus transposition (SRT) technique for patients with Esotropic DRS.5-7 The purpose of this study was to compare the results of medial rectus muscle recession alone with medial rectus muscle  recession (MRc) combined with Superior rectus transposition (SRT) for treatment of esotropic Duane Retraction Syndrome. 

Patients and Methods

The medical records of patients treated in the Department of Pediatric Ophthalmology & Strabismus at Indira Gandhi Eye Hospital and Research Centre, Lucknow between January 2011 and December 2016 were reviewed. Patients who had undergone medial rectus muscle recession with or without superior rectus transposition for the treatment of esotropic DRS were included in the study.

Information extracted from case records were preoperative and postoperative head turn, horizontal and vertical deviation in all gaze positions, ductions, BSV and stereopsis. Information regarding postoperative complications, including surgically induced vertical deviation, diplopia and impairment of adduction were also extracted. Ductions were graded on a scale from 0 to -5 scale (0 – indicating full ductions, − 4 unable to move beyond the midline and −5 eye was unable to reach the midline) Head turn measurements (measured at distance fixation) were recorded from patient records.

Surgical Technique

5.0 – 6.0 mm medial rectus recession was done through a limbal incision in all patients.  In SRT group, limbal conjunctival incision was made from 12 to 3 O’ clock and superior rectus muscle was isolated. After clearing the muscle from surrounding attachments, the muscle was secured with a double arm 6-0 polyglactin (Vicryl) suture. The superior rectus muscle was detached from the globe and was reattached adjacent to lateral rectus muscle along the Spiral of Tillaux. A double armed 5-0 polyester augmentation suture was then placed by passing one needle through the lateral one quarter of the superior rectus muscle and the other needle through the superior one quarter of the lateral rectus muscle, positioning this suture 8 mm posterior to the insertion of the two muscles.8, 9 The suture was then tied to pull the two muscles together similar to loop myopexy, 10 with no scleral pass.

Patients were examined on first postoperative day, at one month post op and six monthly thereafter.

Results

Medical record review identified 12 patients of esotropic DRS treated with MRc alone and six patients treated with MRc combined with SRT over the study period. Patients were between 8 and 23 years of age. Eight patients were male and 10 were female. Left eye was involved in 14 patients and right eye in 4 patients.. The average postoperative follow-up was 13 months (range 1– 52 months) in MRc group and 5 months (range 1 – 12 months) in SRT group. Compensatory head turn was more than 20° in all patients. 5.0 – 6.0 mm medial rectus muscle recession was done in all patients. Augmentation sutures without securing to sclera were placed in all patients in SRT group. The preoperative and postoperative deviation in MRc group was 22 PD and 6 PD respectively.  In the SRT group, the mean preoperative and postoperative deviation was 24PD and 4PD esotropia respectively. The success rate (alignment within 10PD of orthotropia) was 70% in the MRc group; 80%, in SRT group. Head turn improved in all patients.  Mean abduction limitation improved from 3.6 to -3.0 units in the MRc group and     -3.5 to -2.4 in the SRT group. Adduction limitation (-1) was observed in all patients.

Discussion

Ipsilateral or bilateral medial rectus muscle recession has been the treatment of choice for esotropic DRS in the past. MRc improves ocular alignment and head posture but has little effect on abduction. Over the past few decades, a variety of vertical rectus muscle transposition procedures have been proposed to improve ocular alignment in patients with abduction limitation. In 2004, Rosenbaum reviewed the results of vertical rectus transposition (VRT) with posterior fixation, orbital fixation, and partial vertical rectus transposition in patients with sixth nerve palsy and Duane syndrome.11 His study showed a marked improvement in the range of binocular single vision of patients who had undergone a VRT with posterior fixation. Surgically induced vertical strabismus is a concern with VRT 1  and also VRT carries a theoretical increase in the risk of anterior segment ischemia, especially if recession of the medial rectus muscle is required.3 Johnston and Crouch  were the first to propose that it might be possible to gain the benefits of transposition surgery by transposing only the superior rectus muscle (with or without medial rectus muscle recession), thus reducing the amount of surgery required as well as the theoretical risk of anterior segment ischemia.4 Since then several investigator have shows encouraging results with SRT with or without medial rectus recession.5-7.

In our study, the results of MRc group are comparable with the SRT + MRc group in terms of ocular alignment but improvement in abduction is greater in SRT group than in MRc alone group. In our experience, MRc + SRT are superior to recession of the ipsilateral medial rectus muscle as the amount of medial rectus muscle recession required tends to cause a new adduction limitation and contributes no chronic abducting force to prevent recurrence.

In conclusion, there was a markedly reduced esotropia in primary position, improved head position in both groups but improvement in abduction was greater in SRT group than in MRc group. Considering these results, we recommend MRc + SRT for patients with profound abduction limitation in which there is no reasonable chance that a horizontal rectus muscle procedure alone will be satisfactory.

References

  1. Ruth AL, Velez FG, Rosenbaum AL. Management of vertical deviations after vertical rectus transposition surgery. J AAPOS. 2009; 13:16–9.
  2. Laby DM, Rosenbaum AL. Adjustable vertical rectus muscle transposition surgery.J Pediatr Ophthalmol Strabismus. 1994; 31: 75-8.
  3. Murdock TJ, Kushner BJ. Anterior segment ischemia after surgery on 2 vertical rectus muscles augmented with lateral fixation sutures. J AAPOS. 2001; 5:323–4.
  4. Johnston SC, Courch ERC Jr, Crouch ER. An innovative approach to transposition surgery is effective in treatment of Duane’s syndrome with esotropia. Invest Ophthalmol Vis Sci. 2006; 47: E Abstract 2475.
  5. Mehendale RA, Dagi LR, Wu C, Ledoux D, Johnston S, Hunter DG. Superior rectus transposition and medial rectus recession for Duane syndrome and sixth nerve palsy. Arch Ophthalmol.2012; 130:195-201.
  6. Yang S, MacKinnon S, Dagi LR, Hunter DG. Superiorrectustransposition vs medial rectus recession for treatment of esotropic Duane syndrome. JAMA Ophthalmol. 2014;132:669-75.
  7. Tibrewal S, Sachdeva V, Ali MH, Kekunnaya R. Comparison of augmentedsuperiorrectus transposition with medial rectus recession for surgical management of esotropic Duane retraction syndrome. J AAPOS. 2015; 19:199-205.
  8. Foster RS. Vertical muscle transposition augmented with lateral fixation. J AAPOS. 1997; 1:20– 30.
  9. Yazdian Z, Rajabi MT, Ali Yazdian M, et al. Vertical rectus muscle transposition for correcting abduction deficiency in Duane’s syndrome type 1 and sixth nerve palsy. J Pediatr Ophthalmol Strabismus. 2010; 47:96–100.
  10. Wong I, Leo SW, Khoo BK. Loop myopexy for treatment of myopic strabismus fixus. J AAPOS. 2005; 9:589–91.

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